Provider Demographics
NPI:1336214998
Name:FREESTONE, GARY MELVIN (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MELVIN
Last Name:FREESTONE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 N RIVERSIDE AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-8071
Mailing Address - Country:US
Mailing Address - Phone:909-875-1144
Mailing Address - Fax:909-875-0640
Practice Address - Street 1:1850 N RIVERSIDE AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8071
Practice Address - Country:US
Practice Address - Phone:909-875-1144
Practice Address - Fax:909-875-0640
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8983TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0089830Medicaid
CASD0089830Medicaid